Palliative Care Of

Veterans: Distinguishing

PTSD From Moral Injury

and the Clinical

Implications

Jason Malcom, LCSW

Ryan Weller, LCSW

Department Of Veterans Affairs

March 7, 2016

Objectives

Be able to define Post Traumatic Stress Disorder (PTSD) and Moral Injury

Recognize manifestations of PTSD and moral injury at the end of life

Discern difference between moral injury and PTSD

Become familiar with approaches to life review when trauma is a part of the story

Audience

Intertwined: War & Trauma

CIVIL WAR: Soldier’s Heart

WWI: Shell Shock

WWII: Neurosis or Battle

Fatigue

Korea: Operational Exhaustion

Vietnam: Post Traumatic Stress Disorder

Defining PTSD

Exposure to traumatic event with actual or threatened death or serious injury

Re-experience the event

Avoid stimuli associated with event

Increased arousal, hypervigalence

Case Example Mr. J is a 68 y/o Vietnam Veteran.

While in the service he was physically and sexually assaulted repeatedly by a fellow soldier. He tells this to the hospice chaplain

As he approaches death, repeatedly checks under bed and does entire house search before bedtime

Has begun shouting out in the middle of the night

Wife is confused – he’s never been diagnosed with PTSD, he has never acted like this before, but she knew to never to be near him and wake him…

Treating PTSD in EOL of Care

Maximize patient safety: place mattress on the

ground if anxious to check under bed

Identify PTSD triggers: if loud noises are a problem, reduce noise or move patient

If history of POW or isolation, may need frequent visits, reassurance; may be uncomfortable with being dependent

If lucid, visits with chaplain, social worker, etc may be helpful for life review

Educate family: new symptoms of PTSD arise when veterans can no longer suppress flashbacks

Moral Injury

Moral Injury definition

Term Moral Injury was coined by Dr.

Jonathon Shay.

Dr. Shay defines Moral Injury as:

“Moral Injury is present when (1) there has

been a betrayal of what is morally correct;

(2) by someone who holds legitimate

authority; and (3) in a high-stakes situation.”

“Moral injury wounds

the soul.”

-Eric Newhouse, Psychology Today

Moral Injury Definition

continued….

With moral injury events are considered morally injurious if they “transgress deeply held moral beliefs and expectations.”

Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.

“Moral injury makes its mark by

creating a flawed sense of who you

were when you were in harm’s way.” -Thomas Gibbons-Neff

What can cause moral injury

Unintentional errors—U.S. military

personnel are well-trained, however

unintentional errors can lead to loss of life

Transgressive acts of others—

transgressions by peers or leaders who

betray expectations in egregious ways

Acts of no choice—”Him or me”

A story of moral injury Thomas Gibbons-Neff article

“Moral Injury Is the ‘Signature

Wound’ of Today’s Veterans” -David Wood, Journalist, NPR podcast

Moral Injury vs. PTSD

PTSD Moral Injury

DSM Diagnosis Yes No

Life Threatening Yes Maybe

Described by Psychological/

Mental

Moral/Ethical/

Social/Cultural

Cause/basis for Real or perceived

threat to life

Betrayal/Shame/

Regret/Transgression

Support/Public

awareness

Medium to High None to Low

Treatments Some EBP Little/Developing

VA recognition High None to Low

Moral Injury vs. PTSD PTSD Moral Injury

Anxiety? Yes Yes

Anger Yes Yes

Anomie (social

instability resulting

from a breakdown

in values/ethics)

Maybe Yes

Withdrawal Yes Yes

Self-harming Yes Yes

“Self-handicapping

behaviors” Yes Yes

“If the (moral) injury is severe enough,

it can be almost impossible to see

yourself in the present.” —Thomas Gibbons-Neff

Treating Moral Injury

We have to first recognize it exists

It is about reconciling the event that caused the injury

Need for a moral discussion

Who is the person’s “benevolent moral authority?

Group; Veteran attends group with fellow veterans

Helping the person to see that he/she is not 100% responsible for the event

Proposed model for treating

moral injury * 8 step approach:

1. Connection

2. Preparation & education

3. Modified exposure component

4. Examination & integration

5. Dialogue with a benevolent moral authority

6. Reparation & forgiveness

7. Fostering reconnection

8. Planning for the long haul

*Moral injury and moral repair in war veterans: A preliminary model and intervention strategy

Treating Moral Injury

VA is testing CBT-Educational frameworks involving: self-forgiveness and making amends

Narrative Exposure Therapy

Expand and reconstruct the experience

Discuss all painful experiences

Become familiar with emotional response

Find relief from sharing story and knowing emotional response

Treating Moral Injury Life Review

Not about collecting facts, but about understand the patient’s perspective of his/her life story

Approach with open-ended questions and wonderment

Reflect back comments that seem like contradictions

Goal: Expand the life story by incorporating new realizations that may comfort or free the patient

Reflect back the revised story to the patient

References American Psychiatric Association (1994). Diagnostic and Statistical Manual of

Mental Disorders (4th and 5th ed.). Washington, DC: American Psychiatric Association.

Gibbons-Neff, T. “Why distinguishing moral injury from PTSD is important.” http://www.stripes.com/opinion/why-distinguishing-a-moral-injury-from-ptsd-is-important-1.333520

Grassman, D. (2009). Peace at last: Stories of hope and healing for veterans and their families. St. Petersburg, FL: Vandamere Press.

Litz, B.T., et al. Moral Injury and moral repair in war veterans: A preliminary model and intervention strategy

NPR Podscast: Moral Injury is the ‘Signature Wound’ of Today’s Veterans

PTSD: National Center for PTSD, Moral Injury in the Context of War. http://www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp

Weller, R. (2013). Coping with trauma and posttraumatic stress disorder (PTSD) at life’s end: Managing life review. In Improving care for veterans facing illness and death (71-83). Washington, D.C.: Hospice Foundation of America.

White, M. and Epston, D. (1990). Narrative means to therapeutic ends. New York: W.W. Norton & Co.